Good nutrition in older adults can be challenging in the best of circumstances. Add a year-long pandemic and months of isolation to common age-related changes in taste, smell, and appetite; oral health problems; impaired mobility and dementia; and weight loss and malnutrition are among the top concerns in nursing homes, assisted living, and other long term care settings moving into the post-COVID world.

From Isolation to Identification

“One of the biggest issues we experienced during the pandemic that presented a nutritional challenge was that family members weren’t able to come in. Not only had they brought in food their loved one enjoyed and shared mealtimes, they also could help recognize and report subtle signs or issues about the resident’s eating habits or intake,” says Lauri Wright, PhD, RDN, LD, national spokesperson for the Academy of Nutrition and Dietetics.

As a result, problems sometimes weren’t recognized until the person was already losing strength and/or weight. “Once someone starts to lose weight, it can start a downward spiral that causes a number of problems. Malnutrition is a killer,” Wright says.

As facilities open up, staff should be on the lookout for residents who might have special nutritional needs.

“We need to watch for residents who are still self-isolating and don’t want to do much, especially those who have experienced weight loss,” says Ashley Langley, LBSW, director of social services at Caraday Healthcare’s Hearthstone Nursing and Rehabilitation in Round Rock, Texas. “These individuals may just need a little extra encouragement and support, or they may need to be assessed for depression or other issues,” says Langley.

Observation Roles Critical

Supervised activities also will give staff an opportunity to observe patients for mobility, balance, gait, and strength problems. “As things open up, we will have more chances to identify mobility impairments before they result in falls or other problems,” says Arif Hussain, DO, a physiatrist in the Chicago area.

“We need to make sure all staff who interact with residents know what signs and red flags to watch for.”
Of course, everyone who interacts with residents is positioned to identify diet- or intake-related warning signals. For instance, Sherry Perry, chair of the board of the National Association of Health Care Assistants and a long-time certified nurse assistant, suggests watching for the following:

• Residents spilling food on themselves when they eat.
• Individuals who aren’t eating or seem disinterested in their food.
• Coughing, eyes watering, or nose running when someone eats or drinks.
• Signs of oral/dental pain, such as bleeding gums, bad breath, wincing or crying when they eat, holding their mouth or face, or saying it hurts when they chew.
  

Nutrition and Rehab

“Nutrition is an important part of rehab, building strength, and even wound care. This is always on our minds, and we are always asking about patients’ intake,” says Hussain. As with anything else, he says, “this requires a team approach. It starts with educating the patients and their families about the impact of nutrition on overall health, strength, and healing. These messages need to be repeated and emphasized by every team member.

“We need to assess patients on admission and regularly thereafter for their ability to self-feed. We need to make sure they get any assistance they need before they lose weight or experience muscle weakening,” he says.

It is important to assess why someone isn’t eating, Hussain says, and this can start with a conversation. “We need to ask patients why they’re not eating. Sometimes it’s simply because they don’t like the food they’re getting. In this case, we can work with the dietary staff to make sure they get the kinds of food they like. Diet needs to be very patient-centric.”

Phyllis Famularo, DCN, RD, CSG, LDN, CDP, CADDCT, senior manager of nutrition services for Sodexo, agrees. “Residents eat better when they have a choice and a say in what foods they have. We almost had a riot when we took hot dogs off the menu,” she says. “We need to track choice and preferences over time and make the foods they want.”

Are Tortilla Chips Taboo?

Dietary restrictions are common for people with various illnesses and conditions. However, there has been a movement in recent years to liberalize diets for elders in long term care.

“It’s the right thing to do from the standpoint of dignity and quality of life,” Wright says. Getting some calories and nutrition into residents, especially those who aren’t eating and are losing weight, is a top priority. If that means giving a person with diabetes a dish of ice cream or someone with high blood pressure a bag of chips, it may be a viable compromise, she says.

“When our residents are eating better and taking in more calories, we can better manage their underlying conditions while we enhance their quality of life,” Wright says.

The key is moderation, Famularo says. “We have found that, for example, most people with diabetes are happy just to have a small piece of cake or pie. We also have lighter desserts because we don’t want to overload anyone with a lot of sugar.”

Read more for an in-depth discussion on balancing risk and choice.

Some Old Ideas Still Apply

There are tried and true guidelines and ideas regarding nutrition that continue to have merit moving forward. For instance, Famularo notes, “We have some meal service and nutrition guidelines we developed at the beginning of the pandemic. We’ve been looking at them to see what works and if we need to revise them. The only thing we really had to change was that we can’t put out a tray of cookies or cheese and crackers. We can’t serve family-style meals.”

Back in 2005, the American Dietetic Association (ADA) reported that under-nutrition affected anywhere from 23 to 85 percent of nursing home residents. This problem, ADA said, was associated with poor outcomes and the risk for increased mortality. At the time, it was determined that many residents with some evidence of malnutrition were on restricted diets.

In 2011, the Pioneer Network released New Dining Standards to address the importance of individualized diets that accommodate both choice and quality of care, issues that continue to be of concern in the post-pandemic world of 2021.

According to Diane Hall, NHA, RD, LDN, president and chief executive officer of BSN Solutions, “We should not only address dining standards but also consider how CMS [Centers for Medicare and Medicaid Services] regulations and USDA Dietary Guidelines fit in the post-pandemic world because they are so closely bound together.”

All of the standards support individualized regular diets from the start that offer a variety of healthy foods and beverages, along with providing opportunities for choice and independence, she says.

Moving forward, suggests Hall, providers should continue to honor meal and snack choices and provide pleasant and diverse dining experiences. “Now is the time to establish effective strategies to promote adequate hydration and nutrition,” she says. “We need to go back to the basics by conducting surveys and audits that include staff, families, and residents.”

At the same time, Wright adds, “It’s critical that we’re screening and rescreening nutritional status. We have tools and assessments for those at risk. We need to be gathering information and devising care plans for anyone who has a drop in intake.”

Everyone’s On Board

Margaret Roche, MS, RD, CDCES, CSG, FAND, founder of Illinois-based Roche Dietitians, has connected with many dietary practitioners during the pandemic. “In the beginning, there was a focus on emergency foods and menus—ways to keep people fed and satisfied when there were shortages or delays in food deliveries,” she says. The vast majority of people she spoke with said they were concerned about residents’ nutritional status.

“Weights are a crucial indicator of nutritional status, and we have systems in place to address this,” Roche says. However, she stresses that monitoring nutrition requires involvement by more than just the dietitian.

“We need to take every opportunity to bring our teams together and ensure that food has nutritional power behind it. We need to double-down on our focus on nutrition, not only at mealtime but during residents’ engagement and socialization as well.”

Dietitians Take the Lead

While nutrition is a team effort, there is no doubt that dietitians have been on the front line during the pandemic. Roche notes that their experiences during the past year can be used to help inform dietary and nutrition policies, procedures, and processes moving forward.

Leadership is key to good dietary practices, Roche says. “No matter how we feed people, we need dietitians involved with dining leaders, and we need to understand and practice what good leaders do in a crisis.” Part of this involves flexibility.

For instance, she says, “We need to be prepared for different types of emergencies—how we can ensure we have adequate food on hand and what we’ll do if we don’t have a fully functioning kitchen staff. We need to have emergency menus and adequate stocks of food.”

Dietitians and dining leaders are trained to be agile in a pinch, Roche says. “We can adapt operationally. We can think about opportunities to promote nutrition, whether that means giving out finger sandwiches instead of cookies at an event or serving smoothies instead of fruit punch. We have the players and systems in place to do this.”

From Mundane to Wonderful

As facilities open up, families may again be able to play a key role in helping to ensure loved ones get adequate nutrition and hydration. However, New York-based physician, medical director, and founder of Patient Pattern Steven Buslovich, MD, CMD, MSHCPM, cautions about the risks of bringing unvaccinated visitors into the facility.

“Visitation comes with a price tag. You have to weigh the risks and benefits,” he says. “Unvaccinated families can drop off food and treats for a loved one, and we can encourage not-for-profit organizations such as schools to bring in pre-prepared meals. These are great ways to connect residents with the outside world and provide them with food they love while keeping them safe.”

Getting residents to eat can be challenging, even in the best of times. As Buslovich notes, “A lot of residents have lost their sense of smell and taste, especially those with dementia. However, they retain interest in texture, and presentation can make a difference.” He says anything that can be done to give residents something different and more fun than what they’re used to can go a long way.

“Like all of us, they don’t want the same thing all the time or to be forced to eat things they don’t like,” he says. “We need to take the time to identify residents, such as those with worsening frailty, who are at greatest risk for malnutrition and address it promptly. At the same time, we need to ensure an individualized, person-centered approach to nutrition and hydration for all of our residents.”

Read More: Medications and Nutrition.

Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.​